Hemorrhagic Cardiac Tamponade Associated with Apixaban: A Case Report and Systematic Review of Literature

Hemorrhagic cardiac tamponade (HCT) is characterized by rapid accumulation of blood in the pericardium causing hemodynamic collapse. We report a case of HCT due to Apixaban use in a patient with renal cell carcinoma, supplemented with a systematic review of pericardial tamponade associated with the use of direct oral anticoagulants (DOACs).

A 62-year-old African American male with a history of metastatic renal cell carcinoma presented with dyspnea while taking Apixaban. He was diagnosed with pericardial tamponade and 800 ml of hemorrhagic effusion was drained. The pericardial fluid analysis was negative for malignancy and suggestive of HCT. He had a complicated hospital course and died several days later.

We searched MEDLINE, EMBASE and other sources for published cases of pericardial tamponade associated with DOACs. Our outcomes of interest included patient characteristics, risk factors, timing from the start of anticoagulation to tamponade, treatment and mortality. Simple descriptive statistics using percentages for categorical variables were used to describe the included cases.

A total of 26 cases were included in the final systematic review after searching MEDLINE, EMBASE and other sources. The mean age was 70 years (range 43-88) with 19 (73%) males. Twelve cases (46%) were associated with Rivaroxaban, 9 (37%) with Dabigatran and 5(19%) with Apixaban. Sixteen cases had elevated INR and 15 had elevated creatinine. Only 2 patients died but 24 had to undergo pericardiocentesis.

Cardiac tamponade is rarely associated with DOACs and elderly male patients with renal and coagulation abnormalities appear to have the highest risk.